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SERVICE REQUEST e ( ERVR 4) Revised 7 <br /> /231"1 <br /> FACILITY ID # RECORD ID # a/3 INVOICE # <br /> FACILITY NAME Donald/Colvin -(ING PARTY } Y /LM,, <br /> SITE ADDRESS u �jTV1 <br /> CITY 09J / CA zlv tt av <br /> ("FR/00MOJe Z70 A-1" 1,C> 0 L. �/� BILLING PARTY / M <br /> DBA PHONE #1 ( 'i/U ) Z-035�. <br /> ADDRESS �J f%•� ' \ /06:,etO'90(2 C-r PHONE 02 <br /> 61`4 ( ) <br /> CITY Con�Gv2o STATE ZIP <br /> APN # pLard Use Application # <br /> r <br /> I BOS Dist � Location Code <br /> CONTRACTOR end/or Jim Thorpe Oil Inc. , <br /> SERVICE REQUESTOR P t BILLING PARTY <br /> DBA Rich-Mart Construction PHONE 01 (209 1368-6.175 <br /> MAILING ADDRESS P.O. Box 357 Fax # (209 )368-1851 <br /> CITY Lodi, STATE CA zip95241-0357 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner operator or agent of some, acknowledge that all site and/or project specific <br /> PHS/END hourly charges associated with this acn ity or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with ell SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE : Q` 1-1t,/�- ��C r <br /> Title: ®��--� Date: <br /> -2 <br /> AUTHOR17ATIDN TO RELEASE INFORMATION: In addition to the abve, wh. nppl icable, 1, the owner, oper4tsc s agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: Service Cade .tel `%' <br /> Assigned to Employee # Date .'.� <br /> Date Service Completed / / Further Action RequCeguuired: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> / 333 rd <br /> r >, <br /> RENS I _/ /_ SUPV _/_/_ ACCT _/_/ UNIT CLK <br /> C <br />